FDA Adverse Event Malfunction Summary report: N

DIMENSION® CLINICAL CHEMISTRY SYSTEM

MDR report key: 2925192 · Received January 22, 2013

Report

Report Number
2517506-2013-00010
Event Type
Malfunction
Date Received
January 22, 2013
Date of Event
December 24, 2012
Report Date
December 24, 2012
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS INC
Product Code
MLM
PMA / PMN Number
K060502
Removal / Correction Number
2517506-11-27-2012-018-C
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
MI, US
Reporter Occupation
MEDICAL TECHNOLOGIST

Narratives

Additional Manufacturer Narrative · 1

ANALYSIS OF THE INSTRUMENT AND INSTRUMENT DATA INDICATE THAT THE CAUSE FOR THE BIASED LOW TACROLIMUS RESULTS IS UNKNOWN. THE ACCOUNT IS NOT USING THE FA3316 REAGENT LOT AND IS SENDING TACR SAMPLES TO AN ALTERNATE LABORATORY. THE REAGENT ISSUE IS UNDER INVESTIGATION BY SIEMENS HEALTHCARE DIAGNOSTICS INC. SIEMENS HEALTHCARE DIAGNOSTICS INC. ISSUED AN URGENT MEDICAL DEVICE RECALL ON 01-15-2013. THE RECALL LETTER CONFIRMED THE COMPLAINT OF LOW QC AND PATIENT SAMPLE RECOVERIES WITH THE DIMENSION TACR FLEX REAGENT CARTIDGE LOT FA3316. THE RECALL LETTER INSTRUCTED CUSTOMERS TO IMMEDIATELY DISCARD ANY REMAINING REAGENT INVENTORY OF LOT FA3316. THE INSTRUMENT IS PERFORMING WITHIN SPECIFICATIONS. NO FURTHER EVALUATION OF THE DEVICE IS REQUIRED.

Description of Event or Problem · 1

BIASED LOW RESULTS WERE OBTAINED ON TACROLIMUS (TACR) ON QC AND PATIENT SAMPLES IN A LOT CROSSOVER STUDY. THE REAGENT LOT WAS NOT PUT INTO USE. THE PATIENT RESULTS WERE NOT REPORTED TO THE PHYSICIAN. PATIENT TREATMENT WAS NOT ALTERED OR PRESCRIBED. THERE WAS NO REPORT OF ADVERSE HEALTH CONSEQUENCES AS A RESULT OF THE BIASED LOW TACROLIMUS RESULTS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
30872 DIMENSION® CLINICAL CHEMISTRY SYSTEM TACROLIMUS (TACR) FLEX® REAGENT CARTRIDGE MLM SIEMENS HEALTHCARE DIAGNOSTICS INC FA3316

Patients

Seq Age Sex Outcome Treatment
1